USING FRAM IN A CHILDREN S SURGICAL UNIT TO UNDERSTAND WORKFLOW AND DESIGN SOLUTIONS TO DAMPEN VARIABILITY Dr Danielle Franklin BM BSc FRCA Safety- II in Practice 14-15 June 2018 Supported by Ernest Leach RCOA Grant
WHO AM I? Full time Doctor, Consultant Paediatric Anaesthetist working 1 in 6 on-call Plymouth University Hospitals Trust Q fellow Association of Paediatric Anaesthetist QI lead I have been given 0.25PA a week for this work June 2018 2
PROJECT MSc in Patient Safety and Simulation Ethics granted by university - deemed service evaluation by the NHS Children are 20% of the population June 2018 3
CHILDREN S THEATRES 5000 procedures a year Range of specialities: ENT, Orthopaedics, Plastics, Max fax, Trauma, General surgery, Oncology, Dental, Gynaecology, Ophthalmology, Paediatric medicine, Urology, Radiology, Endoscopy Elective and emergency work Theatres open 08:00-20:00 Monday to Friday Emergency cover 24/7 Specialist staff ODP, anaesthetists, nurses, surgeons June 2018 4
HOW DO YOU GET YOUR OPERATION? UNDERSTANDING THE SYSTEM June 2018 5
UNDERSTANDING THE SYSTEM Drawn by Danielle Franklin Take a guided tour at: @PlymChildrenGT June 2018 6
HOW? FRAM Interviews (n=12) Observed practice (20hrs) Learning from Excellence(6 months) Workshops (x2) June 2018 7
FUNCTIONS IDENTIFIED OVER 30 IDENTIFIED June 2018 8
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Before arrival Finalise theatre list Child scheduled Create work schedule Medications Physical space Culture Child arrival Guidelines Admit patient Coordinate patient flow Coordinate clinician flow Consult with surgeon Consult with perioperative practitioner Mark off theatre list Attend team brief Consult with anaesthetist Weigh child Deliver sedative medication Collecting first patient Patient ready for theatre Provide competent staff IT support Provide equipment Apply TED stockings Deliver premed Put on Book bed appropriate clothing June 2018 12
MARK OFF THEATRE LIST A CORE FUNCTION IDENTIFIED FOR SMOOTH RUNNING OF LISTS June 2018 13
Mark off theatre list I just know how to do it June 2018 14
Mark off theatre list June 2018 15
VARIABILITY Everyone marked off on the theatre list in a different way Identified that this was a keep step Not all team members understood importance of this list Not identified clearly Anaesthetist Surgeon Nurse Weight Order Premedication TEDS Pregnancy June 2018 16
HOW DO WE GET A THEATRE LIST? June 2018 17
SCHEDULE CHILD June 2018 18
Finalise theatre list IMPACT OF CHANGES TO PLANNED WORK June 2018 19
LOOSING THE TACIT KNOWLEDGE OF THE SYSTEM Example of theatre scheduler for planed period off Limited planning for training up the temp Use example of late booking We can use the FRAM to show the consequences of actions and predict Review way work done Predict the issues Couldn t deliver this at this time to the management Need facilitator Need engagement at operational level June 2018 20
PROVIDE COMPETENT STAFF June 2018 21
IDENTIFYING STAFF SKILLS Tasks to be completed Prepare child and family Premedication Wrist bands Ametop Observations Patient weight TEDS Pregancy test Gown Pre-operative checklist Allergies identified Pre-operative assessment Starvation status Patient needs June 2018 22
CHANGES June 2018 23
CHANGE IDEAS Staff tabards Competencies List coordination VTE Gowns Labelled rooms Moved pre-op rooms June 2018 24
UNEXPECTED CONSEQUENCES June 2018 25
Nursing culture Threatened WAD exposed Scheduling issues These are all big issues above where I sit in the organisation. June 2018 26
WHERE NEXT? Staff are resource Lots of knowledge Pre-admission FRAM Lack of knowledge of actual WAD Management June 2018 27
1. How do you present this back to the non expert? 2. What should we measure? Leading indicators June 2018 28
THANK YOU Thank you to all of the staff at Plymouth Children s Theatres Thank you to Laura Pickup and Su Smith as my supervisors daniellefranklin@nhs.net Twitter @dkf101 #PlymFRAM June 2018 29